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Some Frequently Asked Questions....

Answer Sources: My intention with this list was to consolidate the common questions that many families who are new to the Ponseti method have asked the veteran Ponseti families. The information here comes from past postings from many different parents and doctors on the on-line parents' support boards that I participate in; a large portion of the information comes from the research conducted by Martin Egbert through his personal research paper (it includes information from many text books) which can be found at the egroups site at: http://groups.yahoo.com/group/nosurgery4clubfoot/files/Reference%20Information and through his personal posts to the aforementioned boards. There is also some information from the intro to Doctor Ponseti's book, which he has given permission to be available at the same egroups site link.

There is also information and opinions that I came by on my own. Please use this information only as a personal starting point and discuss everything with your physician.

This information was reviewed by Dr. Ponseti in January 2001 for accuracy.

1. What causes clubfoot?

The cause is unknown, although genetic and environmental factors may play some role in the development of clubfoot. The term idiopathic congenital clubfoot is the common term for clubfoot in an otherwise normal child. The definition of idiopathic follows: arising spontaneously or from an obscure or unknown cause. The definition of congenital: existing at or dating from birth. Congenital is also defined as: acquired during development in the uterus and not through heredity. Clubfoot develops in a normal foot after 14-16 weeks of pregnancy.

2. How common is clubfoot?

There are differing estimates of the rates of incidence ranging from 1:500 to 1:1,000 births. The March of Dimes statistic is 1:735. Ratio of male to female is 2:1 to 3:1. 40% of cases are reported to be bilateral (both feet). If one child in a family has clubfoot, the chances for a second child having clubfoot are 1 in 35 (2.9%). In identical twins, both children have clubfoot only 32.5% of the time. In non-identical twins, the chances are the same as non-twin siblings that both children will have clubfoot, 2.9%. If one parent has clubfoot, the chances that they will have a child with clubfoot are 3%.

3. What is a heel cord tenotomy?

A tenotomy is a subcutaneous (under the skin) sectioning of the Achilles tendon. As a part of the final casting appointment, a scalpel is used to make a small incision in the back of the ankle under local anesthetic (some doctors use general anesthetic) to lengthen the Achilles tendon. The incision is so small that stitches are not needed. This procedure is intended to complete the correction of the equinus of the foot (allow the toes to lift and the heel to drop). This in-office procedure is needed in approximately 75% of cases treated with the Ponseti method. The final cast is left on for 3 weeks to allow the tendon to heal completely. There are some other types of tenotomies used by other physicians that are more involved than the procedure described here. An open incision heel cord lengthening would need to be done under a general anesthesia where the Achilles tendon is cut in a z-lengthening procedure and stitched back together with extra length. When done, casts need to be worn for about 6 weeks while it heals. The 3rd way the Achilles tendon is lengthened is as a part of a posterior release type procedure. This begins with an open incision Achilles tendon lengthening and then the doctor usually cuts, lengthens up to 5 other ligaments/joints. Then if that isn't sufficient to correct the foot, the doctor can proceed with additional release types of procedures called medial, lateral and plantar releases. These releases involve up to an additional 25-30 things being cut, lengthened, etc. A release type of procedure is what the Ponseti method only needs to do about 2% of the time. The procedures that can be done as a part of a Posterior release or the other types of releases are defined at the Wheeless Textbook of Orthopedics at http://www.medmedia.com/o14/120.htm When a release type of procedure is done, casts need to be worn for about 10-12 weeks to allow for healing. For many doctors, the casts are changed at least once during that period.

4. What is a surgical (posterior medial) release?

With major clubfoot surgery, typically an incision is made circling 1/2 to 2/3 of the foot. Cutting and stitching is done to ligaments and tendons and sometimes pinning of the bones inside the foot. Post-surgical casts are then used from 8 weeks to 12 weeks. These types of surgeries have to be done under a general anesthesia. These are the types of surgery that are done 60-95% of the time after following a more traditional (or Non-Ponseti) method of casting.

5. How many casts does it take to correct clubfoot?

According to Doctor Ponseti, his casting method is 97% successful and takes 1.5-2.5 months of casting (typically 5-7 casts but can be up to 9).

6. Why is the Ponseti Method of casting different than other casting methods?

Based on what I've read and from my discussions with Doctor Ponseti, the biggest factor in the difference between his casting method and what others implement stems from a profound understanding of the structure of the foot and how it can be manipulated to obtain correction. There is a certain way that the components of the foot need to be moved to obtain the correct positioning. From Doctor Ponseti's intro to his book, Congenital Clubfoot Fundamentals of treatment, here are his guidelines for treatment:

1) All of the components of the clubfoot deformity have to be corrected simultaneously with the exception of the equinus which should be corrected last.

2) The cavus, which results from a pronation of the forefoot in relation to the hindfoot, is corrected as the foot is abducted by supinating the forefoot and thereby placing it in proper alignment with the hindfoot.

3) While the whole foot is held in supination and in flexion, it can be gently and gradually abducted under the talus secured against rotation in the ankle mortice by applying counter-pressure with the thumb against the lateral aspect of the head of the talus.

4) The heel varus and foot supination will correct when the entire foot is fully abducted in maximum external rotation under the talus. The foot should never be everted.

5) Now the equinus can be corrected by dorsiflexing the foot. The tendon Achilles may need to be subcutaneously sectioned to facilitate this correction.

In my own experience, here's what I've seen Dr. Ponseti do: he uses his fingers to feel where all the components of the foot are positioned. He knows how to gently move the foot gradually into a corrected position. He holds the foot at a certain position as it is casted into place. The foot isn't "forced" into a "normal" position at each casting session, as is common with some casting methods. The positions that it is put into look quite odd at first, but each week, when the cast is changed, progress is obvious. The entire key to the method is understanding "how" to move the components of the foot.

7. What is Arthrogryposis?

Arthrogryposis is when more than one joint is contracted, such as the hand, in addition to the clubfoot. Arthrogryposis is generally more difficult to treat than idiopathic congenital clubfoot due to the typical severity and rigidity of the clubfoot. Relapses are more common in cases of arthrogryposis. Here are some links for other sites related to Arthrogryposis that were recommended by another mom:

http://www.groups.yahoo.com/group/avenues (many pictures of children and adults, fabulous listserv community)

http://members.aol.com/amcchat/amcinfo.htm Best everything in one place site. This is site put up by a parent of a teenager with Arthrogryposis. He has links to EVERYTHING.

http://www.sonnet.com/avenues/ Official site of parent run organization, sends out snail mail newsletter quarterly, also has online newsletter. The aformentioned listserv is an outgrowth of this community.

8. How does one contact a doctor trained in the Ponseti Method? How does one contact Doctor Ponseti?

9. Can clubfoot be detected by ultrasound?

Clubfoot can best be detected by ultrasound between 20-24 weeks. Clubfoot can start to develop in a normal foot at 12-14 weeks gestation, but Doctor Ponseti told me that clubfoot often develops after 18 weeks gestation.

10. What is a DBB or FAB?

DBB is an acronym for Denis Browne Bar. What is currently used is similar, but not actually the same as a Denis Browne Bar. The correct term is FAB, which is an acronym for Foot Abduction Brace. It is also known as derotational shoes and splint. It is a brace worn after correction is obtained to prevent relapse. The brace has two open-toed shoes mounted at outward angles on a bar. The bar has an adjustable width, so that the heels of the feet can be spaced at the same distance as the child's shoulder width.